Benefit Solutions Licensed in NJ Network Benefit Solutions Licensed in NY
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Proposal Request Form
(Quotes will be faxed to you within 24 hours)

NJ Small Employer Reform Products

Group Information:

Group Name:
Contact Name: Email Address:
Telephone #: ( )- Fax #: ( )-
City: County:
State: Zip:

Broker Information:

Agency:    
Broker: Email Address:
Telephone #: ( )- Fax #: ( )-
City: State:
I have no broker.

Census Information

Download census form
         1-10 Employees
            11-50 Employees
            50+ Employees- Contact us directly at 1-800-57-BENEFIT

(Proposals over 10 employees must be faxed: Proposal Request Form to 973-305-1525 or emailed to info@benefitsolutions.com)

Renewal Date:
 
# of employees working 25 or more hours per week      


Current Plan Information:

Plan 1
Plan 2
Plan 3
 
# of employees currently covered on the plan:
 
Carrier Name:
 
Plan Type:
   
Referral Required:
 
Copay:
PCP:
PCP:
PCP:
Specialist:
Specialist:
Specialist:
 
Separate Hospital Copay:
 
Deductible:
In-Network:
In-Network:
In-Network:
Out-of-Network:
Out-of-Network:
Out-of-Network:
   
Coinsurance:
In-Network:
In-Network:
In-Network:
Out-of-Network:
Out-of-Network:
Out-of-Network:
 
MOOP:
(Maximum Out of Pocket including deductible)
 
          Separate           Separate
          Separate
          Combined           Combined
           Combined
 
In-Network:
In-Network:
In-Network:
Out-of-Network:
Out-of-Network:
Out-of-Network:
 
Rx card:

If yes,
 
          Rx Deductible:
 
          Rx Copay:
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
 
Employer contributions:
 
For Employee:
Percentage:
 Flat Amount $
Other: 
 
For Dependent:
Percentage:
 Flat Amount  $
Other: 

*Physician Search: If you would like us to only search insurance carriers that your physicians participate in, please supply us in the special comment section below the following: Exact Physician name(s), City, County & Specialty or download the attached form. Physician Search Form

Other interests:
                       
Dental
Life
Vision
Consumer Driven Health Plans
HSA (Health Savings Accounts)
HRA (Health Reimbursement Arrangements) 
FSA (Flexible Spending Accounts)
Disability   
Discounted COBRA administration
HIPAA Privacy and Security Compliance
Pension/ 401-k plans
Voluntary Employee Benefit Plans
Long Term Care
Human Resource Support Services
Other 

Special Comments or Instructions

 
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